How Does the Social Security Administration Decide if I Qualify for Disability Benefits for Congestive Heart Failure?

If you have congestive heart failure, Social Security disability benefits may be available. Congestive heart failure (CHF) is called chronic heart failure by the Social Security Administration. To determine whether you are disabled by CHF, the Social Security Administration first considers whether your heart failure is severe enough to meet or equal a listing at Step 3 of the Sequential Evaluation Process. See Winning Social Security Disability Benefits for Congestive Heart Failure by Meeting a Listing. If you meet or equal a listing because of CHF, you are considered disabled.

If your chronic heart failure is not severe enough to equal or meet a listing, the Social Security Administration must assess your residual functional capacity (RFC) (the work you can still do, despite your heart disease), to determine whether you qualify for disability benefits at Step 4 and Step 5 of the Sequential Evaluation Process. See Residual Functional Capacity Assessment for Congestive Heart Failure.

About Congestive Heart Failure and Disability

The Cardiovascular System

Before discussing heart failure, a brief description of the cardiovascular system is needed. The heart is normally a four-chambered muscle situated behind and to the left of the sternum (breast bone). The upper chambers are the left atrium and right atrium. The lower chambers are the left and right ventricles. The ventricles are much larger than the atria (see Figure 1 below).

Figure 1: An anterior view of the heart, featuring the atria, ventricles, and arteries.

Oxygen depleted blood from the veins returns to the heart from the body’s tissues. It enters the right atrium and flows through the tricuspid valve into the right ventricle. The right ventricle pumps blood through the pulmonary valve and into the pulmonary arteries for re-oxygenation by the lungs.

Oxygenated blood from the lungs returns to the left atrium of the heart by pulmonary veins and passes through the mitral valve into the left ventricle. From the left ventricle, newly oxygenated blood is ejected through the aortic valve into the aorta, which is the parent artery of all of the body’s other arteries (see Figure 2 below).

Figure 2: The heart during contraction.

The arterial system of the body that receives blood pumped out of the left ventricle is known as the systemic circulation. The blood moving from the right ventricle through the lungs is called the pulmonary circulation. The valves are important because they open only in one direction, so that blood flow always moves the right way when the heart contracts.

What Is Congestive (Chronic) Heart Failure?

Congestive heart failure, called chronic heart failure by the Social Security Administration, is the inability of the heart to pump enough oxygenated blood to the body tissues (see Figure 3 below). Congestive or chronic heart failure (CHF) affects about 5 million people in the U.S., and is increasing due to the aging of the population.

The heart’s ability to pump blood may be impaired by a variety of causes including myocardial infarction (heart attack), ischemic heart disease (decreased blood flow to heart muscle, usually as a result of coronary artery disease), and cardiomyopathy. The failure of the ventricles to pump blood efficiently results in blood accumulating in the heart, and enlargement of the ventricles.

Figure 3: The heart pumps blood through an immense network of veins and arteries.

Right Heart Failure

Failure of the right ventricle is known as right heart failure. In right-sided failure, there tends to be congestion (fluid accumulation) in organs such as the liver and peripheral edema (swelling) in the feet, because of pressure transmitted back through the venous system. Cor pulmonale—heart disease caused by lung disease—is the main cause of right-sided failure.

Left Heart Failure

Failure of the left ventricle is known as left heart failure. In left-sided failure, pulmonary edema is expected because of increased pressures transmitted back to the pulmonary vascular system.

Ischemic heart disease affecting the left ventricle is usually responsible for left-sided failure. However, the two sides of the heart do not operate in isolation: failure on one side will be associated with failure of the other side, so there are no abnormal findings that are characteristic of only right or left types of heart failure. See Can I Get Social Security Disability Benefits for Ischemic Heart Disease?

Systolic Failure

Predominant systolic dysfunction or systolic failure is the inability of the heart to contract normally and expel sufficient blood. It is characterized by an enlarged, poorly contracting left ventricle and reduced ejection fraction. Ejection fraction (EF) is the percentage of the blood in the ventricle pumped out with each contraction. Most of the claims for disability benefits seen by the Social Security Administration involve systolic heart failure.

Diastolic Failure

Predominant diastolic dysfunction or diastolic failure is the inability of the heart to relax and fill normally. It is characterized by a thickened ventricular muscle, poor ability of the left ventricle to distend (stretch), increased ventricular filling pressure, and a normal or increased EF. Twenty to 40% of heart failure is due to diastolic dysfunction. Some people have both systolic and diastolic dysfunction.

Symptoms and Signs of Congestive Heart Failure

To establish that you have chronic heart failure for the purpose of receiving Social Security disability benefits, your medical history and physical examination should describe characteristic symptoms and signs of pulmonary or systemic congestion or of limited cardiac output. And these signs and symptoms should be associated with the abnormal findings on appropriate medically acceptable imaging. Factors that cause heart failure, but that can be improved or eliminated, such as heart failure induced by high altitude, arrhythmias, and dietary sodium overload, would not be expected to result in chronic failure.

Rales (abnormal breath sounds heard with a stethoscope listening over the lungs, especially the bases of the lungs).

Peripheral edema (fluid retention and swelling in the extremities).

Rapid weight gain.

However, these signs need not be found on all examinations because fluid retention may be controlled by treatment.

Prognosis and Mortality in Heart Failure

Available statistics regarding mortality vary, but there is general agreement that, at the time of diagnosis, CHF has a 5-year mortality in the 35-50% range. This very general number shows what a serious diagnosis is involved, but there are great differences in individual mortalities that are determined by age, sex, race, cause of failure, as well as the nature and severity of other medical disorders. For example, mortality is higher for African-Americans than Caucasians, higher for males than females, higher for age than youth, higher in diabetics, and higher in those with hypertension.

Continue to Winning Social Security Disability Benefits for Congestive Heart Failure by Meeting a Listing.

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